Minnesota Statutes
Chapter 144A — Nursing Homes And Home Care
Section 144A.4794 — Client Record Requirements.

Subdivision 1. Client record. (a) The home care provider must maintain records for each client for whom it is providing services. Entries in the client records must be current, legible, permanently recorded, dated, and authenticated with the name and title of the person making the entry.
(b) Client records, whether written or electronic, must be protected against loss, tampering, or unauthorized disclosure in compliance with chapter 13 and other applicable relevant federal and state laws. The home care provider shall establish and implement written procedures to control use, storage, and security of client's records and establish criteria for release of client information.
(c) The home care provider may not disclose to any other person any personal, financial, medical, or other information about the client, except:
(1) as may be required by law;
(2) to employees or contractors of the home care provider, another home care provider, other health care practitioner or provider, or inpatient facility needing information in order to provide services to the client, but only such information that is necessary for the provision of services;
(3) to persons authorized in writing by the client or the client's representative to receive the information, including third-party payers; and
(4) to representatives of the commissioner authorized to survey or investigate home care providers under this chapter or federal laws.
Subd. 2. Access to records. The home care provider must ensure that the appropriate records are readily available to employees or contractors authorized to access the records. Client records must be maintained in a manner that allows for timely access, printing, or transmission of the records.
Subd. 3. Contents of client record. Contents of a client record include the following for each client:
(1) identifying information, including the client's name, date of birth, address, and telephone number;
(2) the name, address, and telephone number of an emergency contact, family members, client's representative, if any, or others as identified;
(3) names, addresses, and telephone numbers of the client's health and medical service providers and other home care providers, if known;
(4) health information, including medical history, allergies, and when the provider is managing medications, treatments or therapies that require documentation, and other relevant health records;
(5) client's advance directives, if any;
(6) the home care provider's current and previous assessments and service plans;
(7) all records of communications pertinent to the client's home care services;
(8) documentation of significant changes in the client's status and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional;
(9) documentation of incidents involving the client and actions taken in response to the needs of the client including reporting to the appropriate supervisor or health care professional;
(10) documentation that services have been provided as identified in the service plan;
(11) documentation that the client has received and reviewed the home care bill of rights;
(12) documentation that the client has been provided the statement of disclosure on limitations of services under section 144A.4791, subdivision 3;
(13) documentation of complaints received and resolution;
(14) discharge summary, including service termination notice and related documentation, when applicable; and
(15) other documentation required under this chapter and relevant to the client's services or status.
Subd. 4. Transfer of client records. If a client transfers to another home care provider or other health care practitioner or provider, or is admitted to an inpatient facility, the home care provider, upon request of the client or the client's representative, shall take steps to ensure a coordinated transfer including sending a copy or summary of the client's record to the new home care provider, the facility, or the client, as appropriate.
Subd. 5. Record retention. Following the client's discharge or termination of services, a home care provider must retain a client's record for at least five years, or as otherwise required by state or federal regulations. Arrangements must be made for secure storage and retrieval of client records if the home care provider ceases business.
2013 c 108 art 11 s 22; 2014 c 275 art 1 s 135

Structure Minnesota Statutes

Minnesota Statutes

Chapters 144 - 159 — Health

Chapter 144A — Nursing Homes And Home Care

Section 144A.01 — Definitions.

Section 144A.02 — Licensure; Penalty.

Section 144A.03 — License Application.

Section 144A.031 — Consideration Of Applications.

Section 144A.04 — Qualifications For License.

Section 144A.05 — License Renewal.

Section 144A.06 — Transfer Of License Prohibited.

Section 144A.07 — Fees.

Section 144A.071 — Moratorium On Certification Of Nursing Home Beds.

Section 144A.073 — Exceptions To Moratorium; Review.

Section 144A.08 — Physical Standards; Penalty.

Section 144A.09 — Facilities Excluded.

Section 144A.10 — Inspection; Commissioner Of Health; Fines.

Section 144A.101 — Procedures For Federally Required Survey Process.

Section 144A.102 — Waiver From Federal Rules And Regulations; Penalties.

Section 144A.105 — Suspension Of Admissions.

Section 144A.11 — License Suspension Or Revocation; Hearing; Relicensing.

Section 144A.115 — Violations; Penalties.

Section 144A.12 — Injunctive Relief; Subpoenas.

Section 144A.13 — Complaints; Resident's Rights.

Section 144A.135 — Transfer And Discharge Appeals.

Section 144A.15 — State Receivership.

Section 144A.154 — Rate Recommendation.

Section 144A.155 — Placement Of Monitor.

Section 144A.161 — Nursing Home And Boarding Care Home Resident Relocation.

Section 144A.162 — Transfer Of Residents Within Facilities.

Section 144A.18 — Administrator's Licenses; Penalty.

Section 144A.1888 — Reuse Of Facilities.

Section 144A.19 — Board Of Executives For Long Term Services And Supports.

Section 144A.20 — Administrator Qualifications.

Section 144A.21 — Administrator And Director Licenses.

Section 144A.22 — Organization Of Board.

Section 144A.23 — Jurisdiction Of Board.

Section 144A.24 — Duties Of The Board.

Section 144A.251 — Mandatory Proceedings.

Section 144A.2511 — Costs; Penalties.

Section 144A.252 — Immunity.

Section 144A.26 — Reciprocity With Other States And Equivalency Of Health Services Executive.

Section 144A.27 — Acting Administrators.

Section 144A.28 — Severability.

Section 144A.291 — Fees.

Section 144A.30 — Pets In Nursing Homes.

Section 144A.33 — Resident And Family Advisory Council Education.

Section 144A.351 — Long-term Care Services And Supports Report Required.

Section 144A.37 — Alternative Nursing Home Survey Process.

Section 144A.43 — Definitions.

Section 144A.44 — Home Care Bill Of Rights.

Section 144A.45 — Regulation Of Home Care Services.

Section 144A.47 — Information And Referral Services.

Section 144A.471 — Home Care Provider And Home Care Services.

Section 144A.472 — Home Care Provider License; Application And Renewal.

Section 144A.473 — Issuance Of Temporary License And License Renewal.

Section 144A.474 — Surveys And Investigations.

Section 144A.475 — Enforcement.

Section 144A.476 — Background Studies.

Section 144A.477 — Compliance.

Section 144A.478 — Innovation Variance.

Section 144A.479 — Home Care Provider Responsibilities; Business Operation.

Section 144A.4791 — Home Care Provider Responsibilities With Respect To Clients.

Section 144A.4792 — Medication Management.

Section 144A.4793 — Treatment And Therapy Management Services.

Section 144A.4794 — Client Record Requirements.

Section 144A.4795 — Home Care Provider Responsibilities; Staff.

Section 144A.4796 — Orientation And Annual Training Requirements.

Section 144A.4797 — Provision Of Services.

Section 144A.4798 — Disease Prevention And Infection Control.

Section 144A.4799 — Department Of Health Licensed Home Care Provider Advisory Council.

Section 144A.482 — Registration Of Home Management Providers.

Section 144A.483 — Agency Quality Improvement Program.

Section 144A.484 — Integrated Licensure; Home And Community-based Services Designation.

Section 144A.51 — Definitions.

Section 144A.52 — Office Of Health Facility Complaints.

Section 144A.53 — Director; Powers And Duties.

Section 144A.54 — Publication Of Recommendations; Reports.

Section 144A.61 — Nursing Assistant Training.

Section 144A.611 — Reimbursable Expenses For Nursing Assistant Training And Competency Evaluations.

Section 144A.62 — Resident Attendants.

Section 144A.70 — Registration Of Supplemental Nursing Services Agencies.

Section 144A.71 — Supplemental Nursing Services Agency Registration.

Section 144A.72 — Registration Requirements; Penalties.

Section 144A.73 — Complaint System.

Section 144A.74 — Maximum Charges.

Section 144A.75 — Definitions; Service Requirements.

Section 144A.751 — Hospice Bill Of Rights.

Section 144A.752 — Regulation Of Hospice Care.

Section 144A.753 — Licensure.

Section 144A.754 — Enforcement.

Section 144A.755 — Information And Referral Services.

Section 144A.756 — Penalty.